Provider Demographics
NPI:1871834960
Name:ASHLEY VALLEY PHYSICIAN PRACTICE LLC
Entity Type:Organization
Organization Name:ASHLEY VALLEY PHYSICIAN PRACTICE LLC
Other - Org Name:ROOSEVELT COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:409 S 200 E
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-3314
Mailing Address - Country:US
Mailing Address - Phone:435-781-0757
Mailing Address - Fax:435-781-2628
Practice Address - Street 1:409 S 200 E
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-3314
Practice Address - Country:US
Practice Address - Phone:435-781-0757
Practice Address - Fax:435-781-2628
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASHLEY VALLEY PHYSICIAN PRACTICE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-14
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health